Thediagnosisand

managementofprimary
hypothyroidism

AstatementmadebytheRoyalCollegeofPhysiciansonbehalfof

BritishThyroid
Association

BritishSociety
ofPaediatric
Endocrinology
andDiabetes

Endorsedby

Thediagnosisandmanagementofprimary
hypothyroidism

Hypothyroidism,underactivityofthethyroidgland,iscommon.Itcanmakepeopleunwellandshouldbetreated
withlevothyroxinetablets,asyntheticformofthethyroidhormonethyroxine(alsoabbreviatedtoT4).Symptoms
ofhypothyroidism,forexampletiredness,arenotspecifictounderactivityofthethyroidgland,andoccurinmany
othersituations.Itisimportanttodiagnosehypothyroidismwithabloodtest,becauseitcanbedangeroustotake
levothyroxineorotherthyroidhormonesiftheyarenotneeded.Wearethereforeveryconcernedthatsome
patientswithandwithoutthyroiddiseasearebeinginappropriatelydiagnosedandmanaged,usinglevothyroxine
andotherthyroidhormones,inwayswhichcompromisepatientsafety.Thisispotentiallyanenormousproblem,
giventhat,inanyoneyear,oneinfourofthepopulationhavetheirthyroidfunctionchecked.

ThevastmajorityofpatientswithsuspectedthyroiddiseasearesupportedverywellinprimarycarebytheirGPs,
andtheircondition,hypothyroidismorotherwise,isappropriatelydiagnosedandwellmanaged.However,some
patientsareinappropriatelydiagnosedasbeinghypothyroid(oftenoutsidetheNHS)andarestartedon
levothyroxineorotherthyroidhormones,whichwillnotonlycausethempossibleharm,butleavesthetruecause
oftheirsymptomsundiagnosedandthereforeuntreated.Thisstatementrefersonlytoprimaryhypothyroidism.
Secondaryhypothyroidismisadifferentconditionandshouldbemanagedbyaccreditedendocrinologistsinthe
samewayasallotherdiseasesofthepituitarygland.

Diagnosisofprimaryhypothyroidism

(a)Thesymptomsofhypothyroidismareverycommon,bothinmanyotherconditionsandeveninstatesof
normalhealth.Itisthereforeessentialthatthyroidfunctionistestedbiochemicallyalongsideacarefulclinical
assessmentoftheindividualpatient.Clinicalsymptomsand/orsignsaloneareinsufficienttomakeadiagnosisof
hypothyroidism.

(b)Theonlyvalidatedmethodoftestingthyroidfunctionisonblood,whichmustincludemeasurementofthe
levelsofthyroidstimulatinghormone(TSH)andfreethyroxine(FT4)inserum.

(c)Thereisnoevidencetosupporttheuseofbodyfluidsotherthanblood(egurine,saliva)totestforthyroid
function,orthemeasurementofbasalbodytemperatureinthediagnosisofthyroiddysfunction.

(d)Theresultsofbloodtestsforthyroidfunctioncanbeinfluencedbyotherfactors,forexampleinsomeillnesses
whichdonotpermanentlydamagethethyroidgland.Inthiscasethetestswillreturntonormalaftertheillness
andthyroidhormonetherapyisnotneeded(andcanbeharmful).

(e)Werecognisethatdifferentmethodsusedfortestingbloodcangivedifferingresults,andwesupportthe
internationalinitiativeforgreaterharmonisationofreferencerangesandoftheunitsusedinexpressingresults.

Treatmentofprimaryhypothyroidism

(a)Theaimofthetreatmentofhypothyroidismistorenderthepatientbacktothenormaloreuthyroidstate.

(b)WhenasufficientdoseofthyroidtreatmentisgiventolowertheTSHtowithinthenormalrange(reference
range)forthetestmethodused,patientsusuallyrecoverfromtheirsymptomsofhypothyroidism.

ThediagnosisandmanagementofprimaryhypothyroidismRoyalCollegeofPhysicians2011

(c) Fine-tuning of TSH levels inside the reference range may be needed for individual patients.
(d) Patients with continuing symptoms after appropriate thyroxine treatment should be further investigated to
diagnose and treat the cause.
(e) Overwhelming evidence supports the use of thyroxine (T4 or tetra-iodothyronine) alone in the treatment of
hypothyroidism, with this usually being prescribed as levothyroxine. We do not recommend the prescribing of
additional tri-iodothyronine (T3) in any presently available formulation, including Armour Thyroid, as it is
inconsistent with normal physiology, has not been unequivocally proven to be of any benet to patients, and may
be harmful.
(f) There are potential risks from T3 therapy, using current preparations, on bone (eg osteoporosis) and the heart
(eg arrhythmia). We note that the extract marketed as Armour Thyroid contains an excessive amount of T3 in
relation to T4. Over-treatment with T4, when given alone, has similar risks.

Treatment of sub-clinical hypothyroidism

(a) Sub-clinical hypothyroidism is dened as being present in a patient when the TSH is above the upper limit of
the reference range (but usually less than 10mU/L) and free T4 levels are within the reference range.
(b) Some patients with sub-clinical hypothyroidism, particularly those whose TSH level is greater than 10mU/L,
may benet from treatment with levothyroxine in the same way as for clinical hypothyroidism, as indicated in
national guidelines (British Thyroid Association, The Association for Clinical Biochemistry, British Thyroid
Foundation. UK guidelines for the use of thyroid function tests. London, BTA/ACB/BTF: 2006.
www.acb.org.uk/docs/TFTguidelinenal.pdf

Patients with normal thyroid function tests

(a) We recommend that those patients whose thyroid blood tests are within the reference ranges but who have
continuing symptoms, whether on levothyroxine or not, should be further investigated for the non-thyroid cause of the
symptoms.
(b) A further opinion or help with these patients may be sought from appropriate specialists on specialist registers of the
Royal College of Physicians or the Royal College of Paediatrics and Child Health.

Summary
(a) Patients with suspected primary hypothyroidism should only be diagnosed with blood tests including measurement
of serum TSH.
(b) Patients with primary hypothyroidism should be treated with T4 using levothyroxine tablets (listed in the British
National Formulary) alone.
(c) There is no indication for the prescription of levothyroxine or any preparation containing thyroid hormones to
patients without an established diagnosis of thyroid disease and thyroid blood tests within the reference ranges.
(d) In patients with suspected primary hypothyroidism there is no indication for the prescription of levothyroxine or any
preparation containing thyroid hormones to patients with thyroid blood tests initially within the normal range. Thus

The diagnosis and management of primary hypothyroidism Royal College of Physicians 2011

patientswithnormallevelsofT4andTSHdonothaveprimaryhypothyroidism,andeveniftheyhavesymptomswhich
mightsuggestthis,theyshouldnotbegiventhyroidhormonereplacementtherapy.

(e)TheRCPdoesnotsupporttheuseofthyroidextractsorlevothyroxineandT3combinationswithoutfurthervalidated
researchpublishedinpeerreviewedjournals.Therefore,theinclusionofT3inthetreatmentofhypothyroidismshould
bereservedforusebyaccreditedendocrinologistsinindividualpatients.

(g)Laboratorieswhichmeasurethyroidfunctioninotherbodilyfluidsbesidesbloodneedtoprovideanalyticaland
clinicalvalidationtodemonstratetheirefficacy.

(h)TheabovestatementsreflectbestpracticeofclinicalendocrinologistsaccreditedbytheRoyalCollegeofPhysicians
andtheRoyalCollegeofPaediatricsandChildHealth.

Original19November2008
Revised14June2011

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ThediagnosisandmanagementofprimaryhypothyroidismRoyalCollegeofPhysicians2011